Making a Difference IN THE HEALTH OF OUR COMMUNITY - COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) - Saint Joseph Mercy Health System
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Making a Difference
IN THE HEALTH OF OUR COMMUNITY
COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA)
Adopted FY2021 for FY2022-24
OAKLAND
A Member of Trinity Health
St. Joseph Mercy Oakland
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2021 Community Health Needs Assessment
TABLE OF CONTENTS
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Community Health Needs Assessment Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2018 CHNA and Implementation Plan Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Community Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Community Resource Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Community Health Needs Assessment Methodology and Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Qualitative Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
CHNA Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Community Forum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Quantitative Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
County Health Rankings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Community Needs Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Trinity Health CARES Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Limitations & Data Gaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Significant Community Health Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Process for Prioritizing Identified Health Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Prioritized Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
SJMO Internal Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
External Community-Based Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Conclusion and Strategic Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Appendix A Community Stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Appendix B U.S. Census Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Appendix C CHNA Survey Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Appendix D CHNA Survey Highlighted Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Appendix E Trinity Health CARES Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
St. Joseph Mercy Oakland
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2021 Community Health Needs Assessment
St. Joseph Mercy Oakland (SJMO)
CHNA FY 2021 for FY 2022-2024
Executive Summary
The Patient Protection and Affordable Care Act (ACA) mandates nonprofit hospitals conduct a comprehensive
Community Health Needs Assessment (CHNA) every three years. St. Joseph Mercy Oakland (SJMO) assembled
County Health Department data, local community input, and expert public health professional contributions in
a CHNA process which included diverse representation from minority, low-income, medically underserved and
broader community populations.
SJMO provides community benefit services to those in need as a core element of the hospitals mission to
“serve together in the spirit of the Gospel as a compassionate, transforming and healing presence within our
communities.” As a member of Trinity Health, this mission guides everything we do.
SJMO completed a comprehensive CHNA May 2020 through February 2021 and presented findings to the SJMO
Board of Directors for review and approval June 15, 2021. No written comments were received on the 2018 CHNA
and Implementation Strategy. The complete CHNA report is available electronically at stjoeshealth.org. To submit
written comments on the CHNA or to request a copy, contact St. Joseph Mercy Oakland, Office of Community
Health, 44405 Woodward Ave., Pontiac, MI 48341.
The SJMO service area for this assessment was defined as cities with at least 75% inpatient discharges within the
hospitals geographic area. These zip codes include the cites of Pontiac, Waterford, Clarkston, Auburn Hills, Oxford,
Bloomfield Hills, White Lake, Lake Orion, Ortonville, Holly and Rochester. The population for these communities is
439,160 residents. Davisburg, West Bloomfield have patient discharges within the hospitals service area but not
within the 75% threshold to officially be included in the defined service area.
The CHNA process included:
• Oakland County Health Department, CHNA Advisory Group and Southeast Michigan (SEMI) CHNA Steering
Committee supported the hospitals CHNA development. Members of these collective groups created and
distributed the electronic survey tool, reviewed significant community health data and supported health needs
prioritization.
• The theme of the SJMO Community Health Needs Assessment is “Making a Difference in the Health of our
Community”. The 2021 survey consisted of 27 multiple choice questions that were made available electronically
via SurveyMonkey. Paper surveys were distributed to residents at strategic community access points to reduce
barriers to completion. Survey questions identified needs related to health care access and health behaviors.
COVID-19 restrictions impacted survey distribution efforts negatively and positively. Negative impacts included
survey fatigue from 2020 Census, 2020 Election and social isolation related COVID-19 anxiety. Positive impacts
include increased virtual engagement, which increased overall distribution and survey access. Specific COVID-19
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2021 Community Health Needs Assessment
questions were included in the survey to capture significant pandemic-related needs. Of the 663 SJMO service
area respondents, 273 surveys (41%) were obtained through paper surveys which were manually entered into
SurveyMonkey. Many, but not all, paper surveys were collected in communities with high representation of
vulnerable residents such as Oakland County Lighthouse, Oakland Hope Food Pantry and other senior housing
locations in greater Oakland community.
• The hospital hosted two unique virtual community forums on January 13 and 20, 2021 in collaboration with
the Michigan Institute for Clinical and Health Research (MICHR) and Oakland County Health Department. These
community forums were hosted to expand SJMO’s understanding of the communities pressing health needs,
barriers to accessing health care needs and help identify ways to address each.
• Health needs were identified through the analysis of data gathered from a variety of primary and secondary
data sources. Primary data was obtained through the survey, community forum and community health
expert interviews. Secondary data included assessment of national, state and local community health data,
demographic reports, Trinity Health CARES data, SJMO patient discharge records and County Health Rankings.
• The CHNA process identified five top health needs for prioritization. During the early months of 2021 the CHNA
Advisory Group, and the SJMO Community Health and Well Being Advisory Committee prioritized the significant
needs using the following framework:
• Key factor in achieving health equity
• Urgency for addressing the need/severity of need,
• Potential impact on the greatest number of people,
• Feasibility of effective interventions/measurable outcomes in three years
• Consequences of inaction
Potential priorities were identified using a ranking system based on how well the potential priorities met the criteria
listed above. Top needs were presented to the SJMO Community Health and Well Being Steering Committee and
the SJMO Strategic Leadership Council prior to presentation for approval and adoption by the hospital board.
The following top needs were identified and prioritized for this CHNA cycle:
1. Behavioral health including mental health and substance use disorders
2 Food Security
3. Access to Care including health education and patient navigation
4. Maternal Health
5. Diabetes and High Blood Pressure
Over the next three years, health improvement programs as identified in the CHNA Implementation Plan will
be carried out with identified collaborative partners according to the plan and metrics collected. Specifics will
be contained in the Implementation Strategic Plan, which is a separate document and located on the hospital
webpage under community benefits at stjoeshealth.org.
St. Joseph Mercy Oakland
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Introduction
About St. Joseph Mercy Oakland
St. Joseph Mercy Oakland (SJMO) is an established health care leader in northern Oakland County, Michigan. The
Sisters of Mercy founded the hospital over 90 years ago in 1927 at the request of the City of Pontiac. The hospital
has grown into a highly rated 443-bed comprehensive community teaching facility. The hospital is part of the Saint
Joseph Mercy Health System, with five hospitals serving Southeast Michigan; and it is a member of Trinity Health,
one of the country’s largest nonprofit health care systems.
Building on our foundation as a world-class hospital, St. Joe’s has invested in the future of its campus and
committed to bringing the best care to community members where they live and work. The hospital campus
features a surgical pavilion, south patient tower with 204 private rooms and recently renovated mother baby unit.
SJMO’s additional services include Bariatric and general surgery, Thrombectomy capable Cardiovascular Care,
24-hour Emergency Center, Women’s Center, Cancer Center, Physical Rehabilitation, Lab, Orthopedic and Radiology
services for patients in need.
We continue to expand services available on campus and at convenient locations across Oakland County, including
imaging and urgent care services in addition to primary and specialty care.
During the COVID-19 pandemic, hundreds of people sought health care through SJMO, which was a beacon
of hope through challenging times. SJMO maintains a signature commitment to patient-centered care and
community outreach providing over $7 million in charity care and community programs and serving more than
20,000 local residents in 2021.
The hospital opened its South Tower in 2014, labeled the most technologically integrated healing environment in
the country by the Oakland Press. Along with eight new health care technologies to assure patient comfort and
safety, the tower is graced with artwork by 80 Michigan artists.
Accredited by The Joint Commission, SJMO is a leader in innovation and improving health care delivery:
Current accomplishments include:
• Grade “A” in Patient Safety from the Leapfrog Group, a national health care rating organization, 2020, 2019, 2018,
2017, 2016, 2014, 2013, 2012,
• First certified Thrombectomy Stroke Program in the country, 2018,
• American Heart Association/American Stroke Association’s Get With The Guidelines®-Stroke Gold Plus
Achievement Award and Target: Stroke Honor Roll Elite Plus Award, 2020, 2019, 2018, 2018, 2017, 2016,
• Most Wired Innovator Award from the American Hospital Association and Hospitals & Health Networks, 2018,
2017, 2016, 2015, 2014,
• Only Michigan hospital rated a Top Teaching Hospital by the Leapfrog Group, 2019,
• Verified Level 3 Trauma Center since 2012,
• Designated a NICHE hospital (Nurses Improving Care for Healthsystem Elders).
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2021 Community Health Needs Assessment
About Saint Joseph Mercy Health System
SJMO is a member of the Saint Joseph Mercy Health System (SJMHS). SMJHS is a health care organization serving
seven counties in southeast Michigan including Livingston, Washtenaw, Wayne, Oakland, Macomb, Jackson, and
Lenawee. It includes 548-bed St. Joseph Mercy Ann Arbor, 497-bed St. Joseph Mercy Oakland in Pontiac, 304-bed
St. Mary Mercy Livonia, 66-bed St. Joseph Mercy Livingston in Howell, and 133-bed St. Joseph Mercy Chelsea.
Combined, the five hospitals are licensed for 1,548 beds, have five outpatient health centers, six urgent care
facilities, more than 25 specialty centers; employ more than 15,300 individuals and have a medical staff of nearly
2,700 physicians. SJMHS has annual operating revenues of about $2 billion and returns about $115 million to its
communities annually through charity care and community benefit programs. For more information on health
services offered at Saint Joseph Mercy Health System, visit stjoeshealth.org.
Nationally, Trinity Health is among the country’s largest Catholic health care systems. Based in Livonia, Michigan,
with operations in 22 states, Trinity Health employs about 129,000 colleagues, including 7,500 physicians and
clinicians. The system has annual operating revenues of $18.3 billion, assets of nearly $27 billion, and returns about
$1.3 billion to its communities annually in the form of charity care and other community benefit programs. For
more information, visit trinity-health.org.
Mission, Vision and Values
At the core of the hospital’s mission is a commitment to care for the poor and underserved.
The hospital’s mission is -- We, Trinity Health, serve together in the spirit of the Gospel as a compassionate and
transforming healing presence within our communities.
Core Values: Reverence, Commitment to Those who are Poor, Justice, Stewardship, Integrity, Safety
Vision: As a mission-driven innovative health organization, we will become the national leader in improving the
health of our communities and each person we serve. We will be the most trusted health partner for life.
Community Health Needs Assessment Partners
As St. Joseph Mercy Oakland embarked on the Community Health Needs Assessment; many collaborative partners
were engaged in the process.
A. Southeast Michigan (SEMI) CHNA Steering Committee and St. Joseph Mercy Oakland Strategic Leadership Council
The Southeast Michigan (SEMI) CHNA Steering Committee was convened in late 2020. The group utilized
regional health system experts to advise the CHNA process and coordinate talent across the health system
to develop shared strategies that address priority needs where possible to advance policy, system and
environmental change.
The St. Joseph Mercy Oakland Strategic Leadership Council was made of diverse senior executives and service
line administrators. This committee provided input into the CHNA prioritization process and will also support
development of the Implementation Plan.
B. CHNA Advisory Group
The Community Health Needs Assessment Advisory Group consisted of a broad range of community partners
including representatives from the Oakland County Health Department, Pontiac and Waterford School districts,
Oakland University, Faith Community Nursing, Pontiac Chamber of Commerce, Oakland County Sheriff
Department, and two community members. The CHNA advisory group meetings were managed by SJMO’s
Director of Community Health and Well Being and started August of 2020. Additional SJMO clinical colleagues
provided feedback during the advisory group meetings based on availability. The CHNA advisory group
members will also support development of the Implementation Plan. You can find a complete list of the CHNA
Advisory Group members in Appendix A.
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2021 Community Health Needs Assessment
C. Oakland County Health Department (OCHD)
The OCHD was a core member of the CHNA process. Members from the OCHD also served on the CHNA
Advisory Group, co-hosting the CHNA Community Forums and participant in both the prioritization and
Implementation Planning workgroups.
D. Outreach to Vulnerable Populations
Input from vulnerable populations was obtained through engagement with Community food panties including
Lighthouse of Oakland County and Oakland HOPE. Paper survey distribution was used to reach technology
challenged residents. City Clerk offices, Libraries and Faith Community Nursing congregations in Pontiac and
Waterford also served as community-based survey distribution points. Paper and phone survey responses were
manually added to the online survey database as needed.
2018 Community Health Needs Assessment (CHNA) Review
All hospitals recognized as a 501(c)(3), must complete a CHNA and adopt an implementation strategy, once every
three years. The first stage of the 2021 CHNA process included review of the 2018 CHNA report, which assessed
the community’s health issues, impediments to care, voids in services and social determinants of health to identify
significant health needs. In addition to the health needs assessment an implementation plan was also produced.
The full 2018 CHNA report is available for review and commentary online at: stjoeshealth.org/cbm.
Each year, SJMO conducts an evaluation of its identified community health needs. Strategic plans and budgets
were updated and realigned to address identified community health needs based upon health and social concerns,
barriers to care, gaps in service, as well as available health education and prevention services. Additional areas of
analysis for the 2018 CHNA included:
• Program alignment with CHNA
• Program costs
• Individuals served
SJMO selected four health needs as priorities to address within its 2018 implementation plan using the metrics
identified above to prioritize community impact, relevancy of programs and appropriate resource allocation.
2018 Community Health Needs
• Behavioral Health and Substance Abuse
• Obesity and Diabetes
• Heart Disease
• Access to Maternal Education
Since the last CHNA in 2018, SJMO responded to these identified community health needs by focusing initiatives to
develop progressive and improved health through the following programs:
Behavioral Health and Substance Abuse
1. Mental health: Decrease negative perception associated with mental illness, improve access to
mental health services and education. Decrease the negative impacts of substance use.
Outcomes
• SJMO established a Social Support Coalition in 2020 to address social isolation among seniors. This coalition
started as a collaboration among the City of Pontiac and Oakland County senior service agencies to form the
Gatekeeper Program. Gatekeepers helped train residents on signs of social isolation and created a network of
volunteers to assess the needs of neighbors. Comfort Care Calls initiated through volunteer services and Spiritual
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2021 Community Health Needs Assessment
Care. Over 2,300 comfort care calls took place between July 2019 and June 2020. Coalition meetings paused
during the pandemic, work addressing social isolation continued in partnership with Community Housing
Network and the City of Pontiac including improved access to COVID-19 vaccines for those with connectivity
and broadband challenges.
• Anti- Stigma program - Initiative offered in collaboration with Community Network Services (CNS) October 2019
through February 2020. The program was designed to increase mental health awareness. The Anti-Stigma team
educated people about the importance of living a self-directed life and striving to reach full potential. Through
education and empowerment, a process of change improved individual’s health and wellness. The Anti-Stigma
team used nontraditional therapies to manage mental and physical disorders. The team emphasized treating
the whole person instead of behavior health symptoms. Poetry, music and personal testimonies were effective
tools of engagement. During the five-month pilot program, 27 adults and four youth were supported. Of the
31 total participants 23 (74%) were able to avoid hospital readmission and reported improved self-esteem and
medication management.
• The hospital facilitated two Drug Take Back Days in 2019 collecting almost 100 pounds of medications. SJMO
also introduced the green barrel program in 2020 to collect medication for onsite disposal.
• Community Health Workers provide Supplemental Security Income (SSI)/Social Security Disability Insurance
(SSDI) Outreach, Access and Recovery (SOAR) coordination support to improve access to benefits for eligible
residents. SOAR coordination was paused in 2020 to adhere with COVID-19 social distancing measures. Prior
to program pause, the 2019 case load reflected 28 closed cases.
• SJMO education/awareness programs included Youth Mental Health First Aid. This program is designed to
teach parents, family members, caregivers, teachers, school staff, peers, neighbors, health and human services
workers, and other citizens how to help an adolescent (age 12-18) who is experiencing a mental health or
addiction challenge. Youth Mental Health First Aid is primarily designed for adults who regularly interact with
young people. The program introduces common mental health challenges for youth, reviews typical adolescent
development, and teaches a five-step action plan to help young people in both crisis and non-crisis situations.
Topics include anxiety, depression, substance use, disorders in which psychosis may occur, disruptive behavior
disorders (including AD/HD), and eating disorders. Parents and community members also have access to a
90-minute virtual mental health program offered by the National Alliance of Mental Illness titled ‘Ending the
Silence’. This virtual program is for teens 14 and over, focuses on awareness and destigmatizing mental health,
and has served over 40 youth since its introduction in 2020.
Obesity and Diabetes
2. Improve access to healthy produce, Support programs and policies that increase healthy weight
and reduce chronic disease among adults and youth.
SJMO addresses the need for access to healthy food in its CHNA implementation plan, based on the goals
of reducing diabetes and obesity prevalence among adults and children in Oakland County, and improving
knowledge of diabetes prevention and nutrition management options for adults and youth in the SJMO
service area.
Outcomes
• SJMO hosts a monthly food distribution program through Forgotten Harvest at the Mercy Place clinic in
downtown Pontiac. About 100,000 pounds of food are distributed annually through this program and 1,241
community members served from July 2019 to June 2020. As part of the CHNA implementation plan, SJMO
worked to increase access to exercise and physical activity programs in the greater Pontiac community through
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2021 Community Health Needs Assessment
partnership with the local School Board, Chambers of Commerce and Senior Centers. The food distribution helps
residents below the Federal poverty. Of the produce recipients who were surveyed, 71% identified an increase in
their annual fresh produce intake. This annual fresh food consumption can be translated to an overall increase in
daily consumption of fresh fruit and vegetable servings.
• Senior Fit: SJMO offered a free exercise program that combines weight management and other health benefits,
such as cardiovascular fitness and avoidance of osteoporosis, with supportive social interaction. It encourages
older adults to exercise their way to a healthier lifestyle, through body strengthening, floor and chair exercises,
and flexibility training. The program has experienced measurable success since 2016. The program currently
supports 20 sites with demand for expansion. The program paused March 2019 in compliance with COVID-19
pandemic orders to suspend in person gym activities until the program resumed virtually.
• Camp Cavell Campership program: SJMO provided 10 summer camp grants and five Leaders In Training
(teen leadership program) grants for Pontiac High school youth to attend summer camp. Camp Cavell provides
a summer camp experience for urban, at risk youth who have limited physical activity and experience barriers
to safe accessible outdoor activity due to built environment. The campership program is a collaborative effort
between Camp Cavell, St. Joseph Mercy Oakland, and the Pontiac School District. Reduces childhood obesity
and promotes healthy lifestyles while also increasing self-confidence and improved mental health.
• Diabetes & Nutrition Education: The diabetes education program, led by pharmacists and dieticians, is
a valuable inpatient chronic disease management course. Designed to effectively support patients with
management of their diabetes, the course includes individual assessment, educational classes, and an
individualized meal plan. Diabetes education is designed to empower diabetics with the knowledge and skills
necessary to improve behaviors, promote better glycemic control and enhance quality of life. Program outcome
benchmark measures included improved physical activity by 60% (32) of participants and medication adherence
for 70% (38) of participants. Of the 52 total participants the behavioral change goals were met for 2020. Future
program goals include a virtual diabetes prevention course in partnership with the Center for Disease Control
and Mercy Place Clinic starting June 2021.
• The subsidized Wellness Center Memberships provided teachers within the Pontiac School District free access to
the hospital’s gym. This membership comes with trainers and health literacy education to improve participants’
eating habits through a focused weight-management program. This comprehensive program included
improved weight outcomes, long-term healthy eating behaviors and mental health support. The program has
been popular with the school district but had to be suspended in the third year due to COVID-19 precautions.
Membership volumes reached 124 teachers who self-reported 41% more physical activity since enrollment in the
Wellness Center membership.
• SJMO leveraged grant funding to establish the Oakland Farm and produce packing site on the grounds of the
hospital’s former east tower. The project goal of the Oakland Farm is to increase access to health education for
local residents and patients.
• The Prescription for a Healthy Oakland program launched September 2019, focuses on “social prescribing” to
encourage healthy eating and active living. SJMO serves as a program referral partner and has supported over
26 referrals since its relaunch in April 2021, after the COVID-19 program pause. Of the 26 SJMO referrals, 22 (84%)
self-reported an increase in daily servings of fresh fruits and vegetables.
• The Walk with a Physician program, which is available to residents of Oakland County, provided opportunity
to learn about health topics from a primary care physician while walking the grounds at the Oakland County
Farmers Market and Clinton River Trail. On average, the Walk with a Physician participants reported a 40%
increase in daily steps per week. Currently, the program is paused and being evaluated based on resources due
to the pandemic.
• SJMO provided funding and volunteer support to the Friends of the Clinton River Trail to address needed
improvements and upgrades to trail road crossing, resurfacing of trail routes, replacement of bridge railings and
instillation of regulatory, safely and mobility features that improve community access. The Clinton River Trail
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2021 Community Health Needs Assessment
(CRT) is a 16-mile, multi-use, linear park that traverses the communities of Rochester, Rochester Hills, Auburn
Hills, Pontiac, and Sylvan Lake. Improving access to physical activity opportunities through the Clinton River
Trail infrastructure enhancements allow for future sustainability of community walking paths.
Heart Disease
3. Improve high blood pressure rates among adults and reduce adverse health impacts of Stroke
and related Heart disease.
Outcomes
• SJMO’s Faith Community Nurses (FCN) facilitated 83 stroke assessments and 622 blood pressure screenings
in 2020. Thirteen (15%) patients were referred to their Primary Care Physician for follow up appointments, two
(2.4%) patients were referred to the SJMO Emergency room for immediate attention and six (7%) patients were
referred to the Stroke Support group for continued patient navigation assistance. SJMO serves as a strong
community partner and health education referral source for those that have detected elevated blood pressure
as a result of heart disease through the FCN stroke risk assessments. Screening volumes were significantly
impacted by the COVID-19 pandemic. These screenings reflected an increase in the risk for a heart attack despite
modification of the healthy blood pressure ranges suggested by the National Stroke Association.
• SJMO provides a Culinary Medicine class that offers plant-based recipe demonstrations that are tailored for
stroke prevention. SJMO’s Registered Dietitian Nutritionist and Board-Certified Lifestyle Medicine Practitioner
guided participants through the culinary and nutrition principles and addressed questions about proper
nutrition from the American College of Lifestyle Medicine. The program started as an in-person course in August
2019 and has transitioned online to provide virtual offerings. During 2020, the average baseline hemoglobin
A1C for program participants was 9.1%. The average hemoglobin A1C after completion of education and follow-
up was 6.6%. Of those participants, the average number of A1C reduction was 3.08.
Access to Maternal Care Resources
4. Improve health outcomes for perinatal health. Improve navigation and access to health care
resources for mothers, infants, children and families.
Outcomes
• Freedom Road Transportation – (FRT) is a transportation reimbursement program for Oakland, Macomb,
Wayne, or Washtenaw County residents who meet transportation assistance criteria. The consumer is
responsible for finding a volunteer driver, and FRT will provide mileage reimbursement to pay the volunteer
driver each month for their transportation services, up to 100 miles/month for people who are not working.
Filling the gap of transportation services is vital and results in fewer cancellations or no-show appointments,
which is crucial to providing efficient, effective care. From December 2020 to March 2021, FRT provided 29 rides
to women seeking maternal care checkups through the SJMO Woman’s Center. As a result of Community Health
Worker referrals to the FRT, there were zero no-call, no-shows at the SJMO woman’s clinic during this same time
frame. FRT has helped address missed prenatal appointments by patients due to transportation barriers.
• Oakland Literacy Council – Woman’s Health Education (WHELL) Project and language learning funded through
SJMO community benefit dollars focuses on improving access to health care services and advancement of
general health knowledge for women in Oakland County who have limited English Language skills. Women are
often responsible for the entire family’s health care coordination. The impact of improving health care literacy
for non-native English speakers has an impact on an entire family’s ability to access health care services or make
healthy decisions.
St. Joseph Mercy Oakland
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2021 Community Health Needs Assessment• SJMO provided a one-year shared community health worker (CHW) at Bernstein Clinic, resulting in improved
access of prevention and education services for uninsured residents and will also maintain its Complex Care
Coordination through the Emergency Department to assist with health care navigation. Over the course of
one year the shared CHW referred seventeen patients from the Bernstein Clinic to SJMO’s Woman and Children
Clinic to access appropriate prenatal care and Social Service support from the Woman, Infant and Children
program (WIC).
• Social care support has become a top priority, especially as a result of the pandemic. SJMO and the other Health
Ministries in Southeast Michigan have collaborated to initiate a Social Care Hub to assist those who need support
with Social Influencer of Health (SIoH) needs. While more work continues, as part of Trinity Health TogetherCare,
all Michigan Health Ministries have integrated SIoH screening into its electronic medical record and have a
Community Resource Directory available to both patients and residents. Social Care includes family support
programs between our health ministry and community-based organizations to address social needs, especially
access to Maternal health resources. In 2020, the CHW team assisted 64 new mothers with social support needs.
Nine of these new mothers (14%) were referred to the WIC program, four (6%) received support with childcare
applications and eighteen new mothers (28%) received transportation assistance.
• Baby Friendly Designation – SJMO maintains its baby-friendly status and the Centering Pregnancy prenatal
support group program. The baby friendly designation is a World Health and United Nations sponsored program
that recognizes hospitals and birthing centers who offer optimal care for infant feeding and mother/baby
bonding. SJMO was the second hospital in Oakland County to gain this status in 2015. The mother-baby team
has developed world-class standards resulting in safer deliveries, improved support for mothers and healthy
baby development. The baby friendly designation has assisted SJMO in achieving a 67% exclusive breastfeeding
rate for new mothers surpassing the 50% target.
• Breastfeeding Support Group – Registered Nursing staff and lactation consultants provide support and
education for families. Consultants are certified by the International Board of Lactation Consultant Examiners
(IBLCE) and are available seven days a week. By introducing and educating mothers early on the effectiveness of
lactation early childhood development and weigh management drastically improve further reducing the rate of
infant mortality within the first three months after birth.1 Breastfeeding is natural, but It can take time, support
and practice to be successful and SJMO provides this guidance and support to new moms.
• Parent Support Group – SJMO offers a virtual opportunity for moms and/or dads to get together and chat, voice
concerns or just hang out. A Registered Nurse is available during these discussions to answer any questions.
This class is dedicated for parents of children from birth to one-year-old. Participant surveys measured
program helpfulness in facilitating referrals to social support resources, improvement in parent and family
communication, and improvement in exclusive breastfeeding rates. A 4% increase in excusive breastfeeding
rates was archived by program participants when surveyed pre and post participation, resulting in a jump from
74% to 78% for the 18 attendees.
Learning from the previous CHNA allows SJMO the opportunity to evaluate its past community health needs
assessment and improve on identified health conditions with a goal to make our community a better place to live,
work and play.
Due to limited resources, as well as a shift to COVID-19 pandemic management, some planned programing was not
implemented by SJMO to address the needs in the last cycle. Despite this, SJMO made measurable collective impact
on its identified health priority objectives from the previous CHNA cycle.
1
https://www.unicef.org.uk/babyfriendly/news-and-research/baby-friendly-research/infant-health-research/infant-health-research-infant-mortality/
St. Joseph Mercy Oakland
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2021 Community Health Needs AssessmentCommunity Description
SJMO’s primary service area is North Oakland County, with unique focus on the Pontiac community. St. Joseph
Mercy Oakland staff cared for over 23,000 inpatients and 270,000 outpatients, experienced nearly 80,000
emergency room visits, and performed more than 12,000 surgeries during the 2020 fiscal year.
The service area for this assessment is defined as cities with 75% inpatient discharges within the hospitals
geographic area. This includes zip the codes of Pontiac, Waterford, Clarkston, Auburn Hills, Oxford, Bloomfield Hills,
White Lake, Lake Orion, Ortonville, Holly, Rochester. The population for these communities is 439,160 residents
SJMO CHNA GEOGRAPHIC SERVICE AREA
Pontiac faces serious social, economic and health challenges. The unemployment rate in Dec. 2020 was 17.5%,
more than twice Michigan’s rate of 7.5% but steadied to 8.5% by March 2021 and continues to be on the decline. In
2019, the median household income was $33,568 compared to $59,584 for Michigan. With a population of almost
60,000, nearly one in three (30.7%) lives below the poverty level, including two out of every three children. Pontiac’s
community composition is 49.3% African American, 26.5% Caucasian, and 17.2% Hispanic, the fastest-growing
Hispanic population in Oakland County.
The city reflects a high Community Need Index rate, which brings together five socioeconomic indicators known to
contribute to health disparity: income, culture/language, education, housing status, and insurance coverage. Higher
scores indicate greater barriers to healthcare. While the average CNI in the US is 2.09, the CNI average in Pontiac is
4.08. Pontiac is a federally designated Medically Underserved Area based on the percentage of people living below
the poverty level, the percentage age 65 and over and the infant mortality rate.
St. Joseph Mercy Oakland
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2021 Community Health Needs AssessmentWhite Lake
Census Data Oakland County Waterford Auburn Hills Bloomfield Hills Pontiac Clarkston Oxford
Lake Orion
Population estimates, July 1, 2019 1,257,584 72,631 24,748 41,945 59,438 31,356 37,026 39,816 22,886
Persons 65 years and over 17.30% 15.20% 10.90% 24.10% 10.90% 15.50% 14.10% 12.80% 13.20%
White alone 75.30% 86.40% 59.60% 81.90% 40.20% 96.60% 91.40% 90.20% 95.30%
Black or African American alone 13.90% 5.40% 17.10% 7.30% 48.80% 0.90% 2.80% 2.80% 0.60%
American Indian and Alaska Native alone 0.30% 0.50% 0.30% 0.30% 0.30% 0.20% 0.10% 0.20% 0.00%
Asian alone, percent 8.20% 2.00% 17.60% 7.60% 1.90% 0.90% 2.00% 3.40% 1.90%
Native Hawaiian and Other Pacific
0.00% 0.00% 0.20% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
Islander alone
Two or more Races 2.30% 3.50% 4.10% 2.00% 6.70% 1.10% 1.90% 2.30% 1.80%
Hispanic or Latino, percent 4.30% 7.00% 5.20% 2.90% 19.60% 2.20% 4.50% 6.20% 4.00%
White alone, not hispanic or Latino 71.50% 82.00% 55.90% 79.60% 25.00% 94.80% 89.20% 85.30% 92.00%
Households with broadband Internet
87.20% 84.90% 86.80% 92.40% 70.80% 87.80% 91.10% 93.40% 90.70%
2014 -18
Disabiltiy, under age 65 years 2014 -18 7.80% 9.60% 7.80% 4.10% 16.60% 7.50% 7.10% 6.60% 4.40%
Persons w/o health insurance, under age
5.70% 8.90% 7.00% 2.90% 14.40% 5.70% 4.70% 4.00% 3.60%
65 years
Persons in poverty 8.20% 10.60% 12.00% 4.80% 31.90% 6.20% 6.20% 4.70% 5.30%
Community Resource Guide
Over several months of compiling social support resources in 2020, SJMO Community Health and Well-Being
department developed a Community Resource guide that is unique to the Cities within the hospital’s CHNA
service area. Creating the Resource Guide allowed the hospital to identify community health resources and gaps
in services within the immediate community. The full resource guide is printable and available upon request. To
obtain a printed copy of the Community Resource Guide contact St. Joseph Mercy Oakland, Office of Community
Health, 44405 Woodward Ave., Pontiac, MI 48341.
Community Health Needs Assessment Methodology and Process
Quantitative and qualitative data was gathered between October 2020 and February 2021 for purposes of this
CHNA. Data collected was utilized to identify the community health needs of the SJMO service area. Potential
community needs were identified by comparing health indicator data for local zip codes to State of Michigan and
National data benchmarks when available. Where zip code data was higher than State and or National benchmarks,
the indicator was identified as a possible community need.
Community input was gathered for qualitative analysis through surveys, community forums, and interviews.
Community leaders and public health expert interviews assisted in representing the interests of underserved
populations with disproportionate minority demographics. The quantitative and qualitative data was reviewed by
the CHNA Advisory committee to establish a thorough list of health needs for the SJMO service area.
The Oakland County Health Department and local community groups also provided input for the 2021 CHNA. No
written comments were received on the 2018 CHNA and Implementation Strategy. The complete CHNA report is
available electronically at stjoeshealth.org. To submit written comments on the CHNA or to request a printed copy
of this report, contact St. Joseph Mercy Oakland, Office of Community Health, 44405 Woodward Ave., Pontiac, MI
48341.
Qualitative Data
Qualitative data is non-numerical data that is observed, descriptive, and subjective. It is related to characteristics
and qualities rather than trends and statistics. Qualitative data is collected through research methods, which
range from surveys to focus group discussions. For SJMO’s CHNA process, qualitative data was obtained through
community forums and surveys.
St. Joseph Mercy Oakland
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2021 Community Health Needs AssessmentA. SJMO Community Health Needs Assessment Survey
The Southeast Michigan (SEMI) CHNA Steering Committee supported development of an electronic survey
via SurveyMonkey, which consisted of 27 multiple choice questions. The survey tool was branded with the
banner “Making a Difference in the Health of our Community” and was utilized by three of the SJMHS hospitals
conducting their CHNAs this year. Survey questions included inquiries on access to care, personal health
behaviors, perceived community health needs, and patient demographics. Several questions inquire about
COVID-19 pandemic conditions and racial equity. The paper and online survey was available from October 1
through November 15, 2020.
The survey was promoted by and distributed through our collaborative partners, the hospital website and social
media accounts, email blasts to city officials and community leaders in businesses, schools and churches, and
SJMO employees and physicians.
SJMO collected 663 survey responses for its service area, 274 (41%) of which were paper surveys, mostly from
vulnerable populations. Survey respondents were predominantly female (81%) and African American (53%).
There was no significant variation in the top needs specified by survey respondents when stratified by specific
race and age groups. The top needs cited by survey respondents included four unique health conditions:
obesity, high blood pressure, cholesterol, and arthritis. Social isolation was self-reported by many 55+
respondents, presumably due to COVID-19.
Due to the pandemic restrictions and cancelation of community events, in-
person surveying techniques could not be used to sample underrepresented SJMO
populations. In order to reach these populations, there was reliance on paper
survey distribution within vulnerable community outlets. Survey dissemination 663 Survey Responses
was primarily conducted through social media and partner networks which
may have further limited the scope of potential respondents and increased the Health Conditions
likelihood for some selection bias. Identified
• Obesity
• High Blood Pressure
• High Cholesterol
• Arthritis
Respondents
• 81% Female
• 53% African American
• 32% College Graduates
• 25% Age 55-64
• 61% emotional health
problems issues since
COVID-19
St. Joseph Mercy Oakland
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2021 Community Health Needs AssessmentSJMO CHNA FY21
Survey Respondents by Age
75+ 1.60%
13.87%
55-64 26.67%
22.40%
35-44 23.20%
9.07%
18-24 3.20%
0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00%
18-24 25-34 35-44 45-54 55-64 65-74 75+
Percent 3.20% 9.07% 23.20% 22.40% 26.67% 13.87% 1.60%
SJMO CHNA FY21
Survey Respondents Race
Other (please specify) 0.53%
Prefer not to answer 6.91%
Black 53.19%
Native Hawaiian/Pacific Islander 0.00%
Multi-racial 2.66%
Hispanic/Latino 8.78%
White/Caucasian 25.80%
Asian 1.06%
Arab/Middle Eastern 0.27%
American Indian/Alaskan Indian 0.80%
SJMO CHNA FY 21
Response by Zip Code
3% 2% 2% 1% 4%
3% 48326
2%
1% 1% 48341
2% 20% 48340
7% 48342
4% 48327
13% 48329
8%
48328
7%
48348
21%
48302
St. Joseph Mercy Oakland
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2021 Community Health Needs AssessmentB. Community Forum
SJMO conducted two community forums with a total of 34 residents on January 13 and 20, 2021. The two
unique virtual forums were held in collaboration with Michigan Institute for Clinical and Health Research
(MICHR) and Oakland County Health Department. Forums were designed to expand the hospitals understanding
of pressing health needs, barriers to health care access and ways to address each. The community forums
provided an opportunity for the hospital to gather input on a variety of community health issues. Discussions
covered various topics but centered on three key items:
1. Identification of significant community health needs
2. Review of access to care barriers
3. Isolation of most pressing community health need
An unanticipated benefit to COVID-19 pandemic was the increased virtual connectivity of the communities
served by the hospital, allowing increased access and opportunity for community leaders and organizations to
provide input to the CHNA process. Community forum participants received email invitations from both MICHR
and SJMO. Incentives were provided to forum participants as compensation for their time. To assure vulnerable
populations were also represented, direct participant solicitation was conducted through phone call invitation of
the SJMO subsidized produce delivery roster.
Another unique value of this year’s community forum was the partnership with MICHR. Trained moderators
supported the two 90-minute sessions. These third-party moderators allowed the SJMO assessment facilitators
to be removed from the forum environment to prevent influence on forum respondents. Below is a summary of
the SJMO community input forum findings.
SJMO COMMUNITY INPUT SUMMARY
Racism, Public Health Crisis - Forum participants were consistent in mentioning race as an element of health
care. SJMO recognizes racism as a public health crisis and works to address the underlying health inequities
that persist in our county and state through cultural competency training and equity programming. The uneven
economic impact of COVID-19 has heightened many pre-existing inequities, including poverty and unemployment
for communities of color. This assessment and forum help the hospital understand community conditions leading
into and during the pandemic. The forums were also able to highlight community assets and resilience factors that
improve health and well-being
St. Joseph Mercy Oakland
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2021 Community Health Needs AssessmentQuantitative Data Gathering
Qualitative data was gathered from national, state and local community health and demographic databases.
A. County Health Rankings
The County Health Rankings are based on a conceptual model of population health that include Health
Outcomes (length and quality of life) and Health Factors (determinants of health). These rankings provide a
revealing snapshot of how health is influenced by where we live, learn, work and play, and provides a starting
point for change in communities. In the 2020, County Health Rankings Report Oakland County ranked sixth of
83 Counties in health outcomes and third of 83 Counties in health factors with first being the best and 83rd the
worst ranking.
2020 COUNTY HEALTH RANKINGS
County Health Outcomes Health Factors
Oakland 6/83 3/83
St. Joseph Mercy Oakland
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2021 Community Health Needs Assessment2020 COUNTY HEALTH RANKING INDICATORS
Health Behaviors Oakland Michigan
Adult Obesity 25% 32%
Food environment index
Index of factors that contribute to a healthy 8.2 7.1
food environment, from 0 (worst) to 10
(best)
Physical Inactivity 19% 23%
Access to exercise opportunities 94% 85%
Excessive drinking 20% 20%
Alcohol-impaired driving deaths 26% 29%
Health Outcomes Oakland Michigan
Poor physical health day (per 30 days) 3.1 4.3
Poor mental health days (per 30 days) 3.5 4.4
Clinical Care Oakland Michigan
Uninsured 5% 6%
Primary care physicians 720:1 1,280:1
Mental health providers 290:1 370:1
Preventable hospital stays 5,392 5,203
Social & Economic Factors Oakland Michigan
Unemployment 3.3% 4.1%
Children in poverty 10% 19%
Income Inequality 4.7 4.7
Physical Environment Oakland Michigan
Severe housing problems 14% 15%
Source: countyhealthrankings.org/michigan
St. Joseph Mercy Oakland
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2021 Community Health Needs AssessmentB. Community Need Index
The Community Need Index (CNI) is a zip code-based score that accounts for a community’s unmet needs with
respect to health care and is publicly accessible.
Dignity Health and IBM Watson Health jointly developed the nationally utilized Community Need Index (CNI) in
2004. This tool helps health care organizations, not-for-profits, and policymakers identify and address barriers to
health care access in their communities.
The CNI aggregates five socioeconomic indicators long known to contribute to health disparity--income, culture/
language, education, housing status, and insurance coverage--and applies them to every zip code in the United
States. Each zip code is given a score ranging from 1.0 (low need) to 5.0 (high need). Residents of communities
with the highest CNI scores are more likely to experience preventable hospitalization for manageable conditions
in comparison to communities with the lowest CNI scores.
The CNI provides compelling evidence for addressing socioeconomic barriers when considering health policy
and local health planning. The tool highlights health care disparities between geographic regions and illustrates
the acute needs of vulnerable zip codes. The CNI equips health care providers with a quantitative tool to asses
and allocate resources where they are most needed to be effective in maintaining a healthy community. Below
is table of the CNI by zip codes within the SJMO service area for 2020:
Zip Code CNI Score City County
48340 4.4 Pontiac Oakland
48341 4.2 Pontiac Oakland
48342 4.8 Pontiac Oakland
48327 2.8 Waterford Oakland
48328 3.2 Waterford Oakland
48329 1.8 Waterford Oakland
48326 3.2 Auburn Hills Oakland
48301 1.4 Bloomfield Hills Oakland
48302 1.8 Bloomfield Hills Oakland
48304 1.6 Bloomfield Hills Oakland
48346 2.4 Clarkston Oakland
48348 1.4 Clarkston Oakland
48360 1.6 Lake Orion Oakland
48362 1.6 Lake Orion Oakland
48359 2.2 Lake Orion Oakland
48462 1.4 Ortonville Oakland
48371 1.2 Oxford Oakland
48386 1.6 White Lake Oakland
48383 1.6 White Lake Oakland
48324 1.4 West Bloomfield Oakland
48350 1.6 Davisburg Oakland
48309 1.8 Rochester Oakland
48442 2 Holly Oakland
Source: cni.dignityhealth.org (2020)
St. Joseph Mercy Oakland
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2021 Community Health Needs AssessmentD. Trinity Health CARES Data
To help standardize how hospitals conduct their CHNA and use data and community input to measure the
relative health and social well-being of a community, Trinity Health partnered with the University of Missouri
CARES to launch the Data Hub in July 2019. Trinity Health Data Hub reports thousands of community health
indicators. Of these, 100 are customized for each hospital to create efficiencies in conducting community health
needs assessments. This also helps in prioritizing communities to receive interventions, and helps leadership
understand how our patient populations compare to our communities. The Data Hub provides easy access to
most current national and local data, and features interactive maps, reports, and resources to serve all cities
and counties across the U.S. It is an effective tool for colleagues and community partners to collaborate.
Economic Stability
St. Joseph Mercy Oakland
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2021 Community Health Needs AssessmentHealth and Health Care
St. Joseph Mercy Oakland
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2021 Community Health Needs AssessmentNeighborhood and Build Environment
E. Limitations & Data Gaps
This assessment was designed to provide a broad overview of the community’s health and well-being and
identify critical issues related to community health in Oakland County. The assessment is not inclusive of every
health-related issue that residents face and does not represent all possible populations of interest. For secondary
data, the most recent year of data available in some cases differs depending on the source and health topic.
Some data in this report cannot be stratified by race, ethnicity, income, education level, zip code, limiting the
ability to explore differences or disparities among some sub-populations.
Gathering community input data on long-term health needs during the pandemic may have increased the
likelihood of bias and/or measurement error. Committee members tried to account for this by strategically
phrasing survey questions so the direct and indirect effects of the pandemic would not skew the responses.
COVID-19 has also posed a profound impact on the community since the previously CHNA cycle. Financial
instability, particularly due to job loss during the pandemic, has exacerbated many of the challenges faced by
families across the county and the state. In consideration of some of these limitations, the process of prioritizing
health needs was based on both quantitative data collected prior to the state shutdown in Michigan, and
qualitative data collected amidst the pandemic.
St. Joseph Mercy Oakland
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2021 Community Health Needs AssessmentF. Significant Community Health Needs
Needs Identified
The CHNA Advisory Group identified eight health needs by reviewing community input through forums and
CHNA surveys. Next, quantitative data for the service area was compared to State and National averages,
revealing five health needs that were both unfavorable to state and national benchmarks and were community
input themes. Through this two-step process, the eight health needs were refined by the CHNA Advisory Group
to five significant health needs that include (1) behavioral health (2) access to care (3) food security (4) diabetes &
high blood pressure and (5) maternal care.
The needs were similar to those identified in the 2018 CHNA but food security replaced healthy eating/nutrition
and a focus on Diabetes and High Blood Pressure was distinguished. The CHNA Advisory and CHWB committees
validated these as significant health needs as priorities within the hospital’s service area that need intervention.
SJMO TOP HEALTH NEEDS
Behavioral Health • Oakland County residents experience 3.5/30 poor mental health days as compared to
(Mental Health and 4.4/30 in Michigan
Substance Abuse) • Oakland County residents partake in excessive drinking at the same rate equal to the
State of Michigan 20%.
Access to Care • 5% of Oakland County residents are uninsured compared to 5% of Michigan
Residents
• 16% of the adults in the CHNA Service Area don’t have a PCP compared to 15%
for Michigan
Food Security • 1 out of 7 people in Michigan experience hunger
• 8.2 Food Environment Index for Oakland County compared to 7.2 for Michigan
• 21% of the adults in the CHNA Service Area are low income with low food access
compared to Michigan at 18%
Diabetes/High • 17.3% of children 10 – 17 years are obese in Michigan
Blood Pressure • 15.3% of high school students are obese in Michigan
• 11.1% of adults with Diabetes are obese in Michigan
• 35.1% of adults with High Blood pressure are obese in Michigan
• 39% of adults f Adults in Michigan have high blood pressure
Maternal Health • The U.S. has the highest infant mortality rate of all developed countries.2
• African American woman are twice as likely to experience infant mortality
than other races.3
countyhealthrankings.org/michigan
State Obesity Data - The State of Childhood Obesity (2019)
Michigan 2018 Behavioral Risk Factor, Annual Report
americashealthrankings.org
2
https://www.savethechildren.org/content/dam/usa/reports/advocacy/sowm/sowm-2015.pdf
3
http://www.mlpp.org/kids-count
St. Joseph Mercy Oakland
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